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Get Harris Health System Residence Verification Form 2012

RESIDENCE VERIFICATION FORM This is an Official Government Record. False or incomplete information given on this form may result in criminal action being taken under Sections 31. 04 37. 04 37. 10 or other portions of the Texas Penal Code. Client Name and Address Date Eligibility Center This client has told us that you are not related to him/her and you do not live in the household but you know the family. Please list all the persons living in the household. Name Relationship to Client Name of Employer Client I can verify the above information because I am a check one Neighbor School Official Friend Church Leader Employer Landlord Child Care Provider Other explain. How long have you known the family years months or weeks. Signature Please print your name address and telephone number below Address Phone 283130 09/12 Front. 04 37. 04 37. 10 or other portions of the Texas Penal Code. Client Name and Address Date Eligibility Center This client has told us that you are not related to him/her and you do not live in the household but you know the family. Please list all the persons living in the household. Name Relationship to Client Name of Employer Client I can verify the above information because I am a check one Neighbor School Official Friend Church Leader Employer Landlord Child Care Provider Other explain. Please list all the persons living in the household. Name Relationship to Client Name of Employer Client I can verify the above information because I am a check one Neighbor School Official Friend Church Leader Employer Landlord Child Care Provider Other explain. How long have you known the family years months or weeks. Signature Please print your name address and telephone number below Address Phone 283130 09/12 Front. 04 37. 04 37. 10 or other portions of the Texas Penal Code. Client Name and Address Date Eligibility Center This client has told us that you are not related to him/her and you do not live in the household but you know the family. Please list all the persons living in the household. Name Relationship to Client Name of Employer Client I can verify the above information because I am a check one Neighbor School Official Friend Church Leader Employer Landlord Child Care Provider Other explain. How long have you known the family years months or weeks. Signature Please print your name address and telephone number below Address Phone 283130 09/12 Front. .

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